Introduction

Jeanette is a 60 year old supermarket checkout supervisor. She lives with her husband Tony who is a long distance lorry driver and they are both current smokers. Jeanette has insulin dependent diabetes and was diagnosed with COPD three years ago.

She uses a short acting beta agonist bronchodilator 2-3 times daily via metered dose inhaler to help her cope with walking between the tills at work and when doing housework.

At her last routine review her FEV₁was 52 percent of predicted and her MRC score was recorded as 2. She has never had a flu jab because she fears it will make her unwell.

Section 1 Jeanette phones her GP surgery one lunchtime asking for advice about her inhaler and the call is put through to the practice nurse. She sounds breathless on the phone and says she thinks the inhaler has run out and “could she have another one as her chest is not so good today?”.

You ask some questions to get an idea of what is happening to Jeanette and find out that she has noticed a change in the colour of her sputum and she is coughing a lot more, she has been feeling hot and cold and aching all over and she has had to have the last 2 days off sick from work because she “just can’t cope with all that walking”. Tony is working away so there is no-one to help her with the shopping whilst she is feeling poorly.

What is the most important issue that will influence Jeanette's likelihood of hospital admission?

Her change in sputum colour

Her increased breathlessness

Lack of support at home

Her co-morbidity of insulin dependent diabetes

indicates the correct answers for this question

Explanation

Section 1 Jeanette phones her GP surgery one lunchtime asking for advice about her inhaler and the call is put through to the practice nurse. She sounds breathless on the phone and says she thinks the inhaler has run out and “could she have another one as her chest is not so good today?”.

You ask some questions to get an idea of what is happening to Jeanette and find out that she has noticed a change in the colour of her sputum and she is coughing a lot more, she has been feeling hot and cold and aching all over and she has had to have the last 2 days off sick from work because she “just can’t cope with all that walking”. Tony is working away so there is no-one to help her with the shopping whilst she is feeling poorly.

A and B confirm that Jeanette is likely to be suffering an infective exacerbation of her COPD. In many patients this could be safely treated at home, especially where there is a community respiratory team to support people during acute exacerbations even in the absence of any family support. A co-morbidity such as Jeanette's diabetes is more of a concern, as acute infection, decreased mobility, poor appetite and oral corticosteroid treatment will have a negative impact on glycaemic control and need careful management, so in this case her likelihood of needing hospital care initially is high.

Section 2 Jeanette phones her GP surgery one lunchtime asking for advice about her inhaler and the call is put through to the practice nurse. She sounds breathless on the phone and says she thinks the inhaler has run out and “could she have another one as her chest is not so good today?”
You ask some questions to get an idea of what is happening to Jeanette and find out that she has noticed a change in the colour of her sputum and she is coughing a lot more, she has been feeling hot and cold and aching all over and she has had to have the last 2 days off sick from work because she “just can’t cope with all that walking”. Tony is working away so there is no-one to help her with the shopping whilst she is feeling poorly.

What general factors are associated with increased risk of hospital admission in people with COPD? (choose all that apply)

Anxiety

Having flu vaccination

Social deprivation

Smoking status

Lack of practice nurses

indicates the correct answers for this question

Explanation

Section 2 Jeanette phones her GP surgery one lunchtime asking for advice about her inhaler and the call is put through to the practice nurse. She sounds breathless on the phone and says she thinks the inhaler has run out and “could she have another one as her chest is not so good today?”
You ask some questions to get an idea of what is happening to Jeanette and find out that she has noticed a change in the colour of her sputum and she is coughing a lot more, she has been feeling hot and cold and aching all over and she has had to have the last 2 days off sick from work because she “just can’t cope with all that walking”. Tony is working away so there is no-one to help her with the shopping whilst she is feeling poorly.

Population deprivation and smoking prevalence were found by Calderon-Larranaga et al (2011) to have a direct association with the risk of admission, whilst good practice nurse staffing levels had a protective effect. Influenza vaccination was found to have the strongest association with reduced admission rates. Anxiety has a strong correlation with the risk of re-hospitalisation in COPD, but not with general admission rates (Gudmundsson et al 2005).

Section 3 The GP visits Jeanette and is worried about her increased respiratory rate and heart rate, temperature of 39.0 degrees centigrade, unstable blood sugars and her inability to cope at home whilst she is unwell. Another concern is that her pulse oximetry reading is slightly low at 90% peripheral oxygen saturation. He arranges for her to be admitted to the medical assessment unit at the local hospital.

How will Jeanette's COPD be managed differently on admission?

She will have the same treatment as at home but closer monitoring of her breathing.

She will need non-invasive ventilation to treat her increased shortness of breath.

indicates the correct answers for this question

Explanation

Section 3 The GP visits Jeanette and is worried about her increased respiratory rate and heart rate, temperature of 39.0 degrees centigrade, unstable blood sugars and her inability to cope at home whilst she is unwell. Another concern is that her pulse oximetry reading is slightly low at 90% peripheral oxygen saturation. He arranges for her to be admitted to the medical assessment unit at the local hospital.

Hospital admission is needed where patients are significantly unwell, in this case aggravated by a combination of long term conditions. In order to determine the best treatment pathway assessment of the underlying cause of worsening symptoms will include a chest X ray to exclude pneumonia or pneumothorax and blood gas analysis to identify any signs of respiratory failure, blood tests such as full blood count and inflammatory markers to assess severity of infection, sputum analysis to help target antibiotic therapy as well as basic observations such as temperature, respiratory rate, heart rate and blood pressure.

The basic principles of treating a COPD exacerbation are to resolve bacterial infection where this is found, and to reduce the inflammation in the airways that is causing increased symptoms, so the drugs used will be the same as if treated at home: antibiotics, steroids and increased dose and frequency of short acting bronchodilators. However management in hospital aims to speedily resolve infection and improve symptoms to ensure the minimum length of stay, or “bed days”, possible, so the use of intravenous antibiotics and higher doses of nebulized bronchodilators is more likely.

Stepping up regular maintenance therapy in COPD is not a priority for admission, but may be considered prior to discharge. The use of non-invasive ventilation is less likely in someone with moderate obstruction (FEV₁ above 50%) as this is used to treat type 2 respiratory failure where oxygen and carbon dioxide levels in the blood are both abnormal: this is more often a complication of severe and very severe obstruction where the lung starts to fail.

Those with severe lung impairment may typically struggle to maintain oxygen levels during acute exacerbations and develop ineffective breathing patterns due to tiredness and weak respiratory muscles, this causes retention of carbon dioxide and needs ventilatory support until the blood gases normalise. For patients with COPD this would mean a period of non-invasive ventilation (NIV, sometimes called NIPPV) in a setting where close monitoring is possible.This involves wearing a close fitting mask which enables positive pressure to be applied to the airways to “splint” them open and improve gas exchange, thus taking away some of the extra work of breathing that ill patients cannot sustain. Non-invasive ventilation is preferred in COPD as this does not involve sedating or paralyzing patients for intubation so there is much less risk of long term ventilation in intensive care being required (RCP/BTS/ICS 2008).

Section 4 Jeanette’s chest x ray suggests a left lobar pneumonia, and this is supported by a raised white cell count, raised CRP and raised urea levels on her admission blood profile. Her blood gas analysis on admission (breathing room air) shows the following parameters:

pH 7.41, HCO3 24 mmol/litre, PaO2 8.8 kPa, PaCO2 5.3 kPa

What does this show?

Normal blood gases.

Type 1 respiratory failure.

Type 2 respiratory failure.

Mild hypoxaemia.

indicates the correct answers for this question

Explanation

Section 4 Jeanette’s chest x ray suggests a left lobar pneumonia, and this is supported by a raised white cell count, raised CRP and raised urea levels on her admission blood profile. Her blood gas analysis on admission (breathing room air) shows the following parameters:

pH 7.41, HCO3 24 mmol/litre, PaO2 8.8 kPa, PaCO2 5.3 kPa

The values are normal except for a low PaO2 suggesting a degree of hypoxaemia, with Jeanette’s increased respiratory rate showing the body’s attempt to improve her oxygen levels.

Type 1 respiratory failure is defined as an abnormality of one arterial gas, with an oxygen level (PaO2) below 8kPa.

In type 2 respiratory failure both gas levels are abnormal, so oxygen levels are low (below 8kPa) and the carbon dioxide levels are too high – a PaCO2 of more than 6.7kPa.

The pH reflects the acidity of the blood, with a normal range being 7.36-7.44. Since carbon dioxide is acidic when dissolved in the blood an increase in this will cause a fall in the pH –acidosis - which if left untreated could ultimately lead to a cardiorespiratory arrest.

Where there is a gradual or chronic increase in the carbon dioxide levels the body responds to acidosis by retaining bicarbonate ions (HCO3) so an increase in this value shows whether the acidosis is acute or chronic in nature (Booker 2008).

Section 5 Jeanette spends 3 days in hospital and shows good improvement in her symptoms, vital signs, and in her blood gases, whilst input from the diabetes team helps stabilize her blood sugars. The discharge team start to plan for her return home and use the local “COPD discharge bundle” as a basis for this.

Which of the following sums up the desired components of a COPD discharge bundle?

Arrange transport home, social services input and TTOs.

Discuss smoking cessation, inhaler technique and adherence, give written information, assess for pulmonary rehabilitation and follow up within 72 hours.

Arrange follow up within 48 hours, adequate supplies of antibiotics and steroids and check inhaler technique.

Start triple therapy, refer to smoking cessation and give a written self-management plan.

indicates the correct answers for this question

Explanation

Section 5 Jeanette spends 3 days in hospital and shows good improvement in her symptoms, vital signs, and in her blood gases, whilst input from the diabetes team helps stabilize her blood sugars. The discharge team start to plan for her return home and use the local “COPD discharge bundle” as a basis for this.

Stepping up to triple therapy by adding in both a long acting muscarinic antagonist inhaler and a medium to high dose inhaled corticosteroid and long acting beta agonist combination may not be required just yet in Jeanette’s case, as her lung impairment is still classed as moderate based on her last spirometry test.

Whilst the items suggested in A and C are important to any patient discharged from hospital, the purpose of a COPD discharge bundle is to structure future care based on the recognised value of certain interventions. COPD patients often do not perceive that they have an illness until they exacerbate (Pinnock et al 2011), so a hospital admission represents an ideal opportunity to engage with such patients and ensure that evidence based interventions are utilized to the full.

The importance of basic steps such as inhaler technique, smoking cessation advice and patient education are paramount in reducing the longer term impact of COPD, and proactive follow up will ensure that patients feel supported, identifying both immediate care needs and how to reduce future risks to their health.

Whilst there has been some limited evidence suggesting benefit of discharge care bundles in COPD (Hopkinson et al 2012), they are as yet not widely implemented although large scale studies are in progress.

Summary

Jeanette is seen 2 days after discharge by her GP and maintenance treatment with a long acting bronchodilator is added to her therapy because prior to her acute episode she needed to use her short acting beta agonist inhaler on a regular basis. Adding a long acting beta agonist (LABA) or a long acting muscarinic antagonist (LAMA) as a regular treatment helps reduce breathlessness symptoms and reduces exacerbation frequency.

She is happy about being referred to pulmonary rehabilitation after talking to the respiratory nurse team involved in the programme whilst she was in hospital. During her admission she was prescribed nicotine replacement patches and has not smoked since, so she has an appointment with Tony to see the practice nurse for support with smoking cessation later in the week. Plans for her future care include Jeanette’s agreement to have the influenza vaccination next autumn, and education about recognition of the signs of exacerbation and supported self-management. These measures should reduce the risk of future admissions and maintain quality of life for Jeanette in the longer term.

Overall score

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This website is supported by unrestricted educational grant from Teva UK Limited. Teva UK Limited has reviewed the content for factual accuracy. | KOL/11/028(1) Date of preparation December 2015 Editorial control of educational content remains with Education for Health.